CH...I know you're suffering from information overload, but the combination of HT, brachy and IMRT would not be used for a G6--at least here in the U.S. That particular combo is generally targeted toward higher risk diagnoses (I had that combo as a G9). A G6 would typically have either brachy or IMRT as a monotherapy--and no HT would be used.

What seems odd to me is that you have a recommendation or AS and another recommendation for the combo therapy--those are two different sides of the spectrum. Good luck...this part of the journey isn't easy.Age 58, Diagnosed at 51PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)Completed HT (18 months) in April 20143/19: PSA = 0.04

I can't thank you all enough for your advice and motivating words. Yes, Michael T, the radioncologist offered the triple play as you say, but it might be too much. Today, I took the slides for a review with a top pathologist in the area and should get results in 5 to 8 days. Then will take the results to the board meeting and listen to the options.

Thanks again everyone. I hope to do the same for other newbies on the forum.

I may be wrong, but what we know about this case is that biopsy shows a moderatly high volume of PCa and the mri show a PIRADS 5, also indicating high volume and high possibility of significant PCa or upgrading. Moreover, mri also shows that the lesion is close to the capsule. BT alone only destroys PCa inside the prostate and this is the reason it is not so safe here. Maybe some kind of external radiation would be more adequate as monotherapy if the final choice is radiation.68 years oldPSA: 2008:2.8; 2012-2016: 4.5-5.5. 2013: two biopsies (ASAP, neg) mpMRI (-).Feb to July 2017: 5.5-7.6; free: 25%-20%mpMRI, July 2017: PIRAD5 5.Dx August 2017,Gleason 3+3, 2 cores, left 5%, right 3%.Prostate > 100 g. DRE +.LRP, nov. 6, 2017.Bilat., 30% and 5%. G 5+3. Clean margins, T2, LVI and PNI (-).Psa: 2018; 1-31:0.08; 4-16: 0.05; 7-16: 0.03; 10-22: 0.07. 2019: 3-20: 0.03.

I recall being shown the active radiation zone from HDR brachy and it does extend beyond the prostate. I don't remember what that distance was...Age 58, Diagnosed at 51PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)Completed HT (18 months) in April 20143/19: PSA = 0.04

BT extends up to about 10mm outside the capsule based on the location of the cancer and intended radiation field. It all depends on the individual and the approach used by the radiation oncologist and team. HDRBT can also extend up into the seminal vesicles and the margin around them.

For both BT ( permanent seeds and HDR) the radiation seed(s) is introduced within the capsule, but the radiation field extends outwards. This field is significantly broader than the excision area of surgery. That is why BT can be more effective than surgery when the PCa is within the surgical margin and extending through the capsule, but within the possible radiation field.

The radiation field is limited by the surrounding organs like the bladder and bowel to limit damage and by the actual strength of the radiation source.PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

I really did not plan to reply. But after three answers telling I am wrong without any source supporting this opinion I just went to the maybe most basic information available, the ACS web: "Brachytherapy alone is generally used only in men with early-stage prostate cancer that is relatively slow growing (low-grade). Brachytherapy combined with external radiation is sometimes an option for men who have a higher risk of the cancer growing outside the prostate."My point is that we are advising somebody with 6/12 positive cores in his biopsy and a mpmri revealing a PIRADS 5 lesion (very high probability of significant PCa). His doctors are recommending combined radiation or surgery and I give him the non-professional and less informed advice to believe them. Despise the biopsy G6, it is not completely clear it is an early-stage low-grase case. I really hope it is, but I was in a similar situation and I know now (after a path report) that I am not low-grade.68 years oldPSA: 2008:2.8; 2012-2016: 4.5-5.5. 2013: two biopsies (ASAP, neg) mpMRI (-).Feb to July 2017: 5.5-7.6; free: 25%-20%mpMRI, July 2017: PIRAD5 5.Dx August 2017,Gleason 3+3, 2 cores, left 5%, right 3%.Prostate > 100 g. DRE +.LRP, nov. 6, 2017.Bilat., 30% and 5%. G 5+3. Clean margins, T2, LVI and PNI (-).Psa: 2018; 1-31:0.08; 4-16: 0.05; 7-16: 0.03; 10-22: 0.07. 2019: 3-20: 0.03.

Be careful, jmadrid, not to mix-up PIRADs meaning with the ISUP grades...it sounds like you are (common mistake, BTW). ISUP grade-5 means Gleason 9 or 10, which is a measure of the risk of recurrence (many simplify and say "aggressiveness") of prostate cancer. But PIRAD-5 means that there is a high suspicion of actually having cancer...and says absolutely nothing about aggressiveness. In this case, with 6 of 12 positive cores, we already knew that he has cancer. (The mp-MRI is most informative in men who had initial negative biopsy results--and therefore don't actually know whether they have cancer or not--but other indications were still strong that there might be undiagnosed/unfound PC.) The OP does not have "very low risk" PC because he had more than 3 positive biopsy cores, but otherwise...

I regularly refer men to the website of Dr. Jeffrey Demanes. He started using HDRBT in 1981 and pioneered HDRBT mono-therapy in 1996. He has been a pioneer in HDRBT for PCa and many other cancers. He also chaired the department at the UCLA Medical Center.

His website is www.cetmc.com. In the PCa section he explains the radiation cloud from HDRBT as extending out at least 5 mm from the prostate capsule and explains it can extend further as warranted. He also explains the coverage of the seminal vesicles.

Another top PCa radiation oncologist is Dr. Alvarez Martinez in Detroit. I read several of his papers on the HDRBT protocol as my radiation oncologist followed the Martinez protocol. He cited that he would extend the radiation cloud out as far as 10 mm as appropriate.

When using permanent seeds it his reported that the radiation cloud extends 3-5mm outside the capsule. Among others so reporting is Dr. Frank Critz in Atlanta. He pioneered the use of concurrent permanent seed brachytherapy with external beam radiation in the 1970’s. His clinic, Radiation Clinics of Georgia has treated more than 20,000 men for PCa.

Thus, the greatest radiation cloud coverage is when HDRBT and IMRT/IGRT are used concurrently. My HDRBT included the seminal vesicles and extended outside the prostate capsule by 10mm in most areas. Due to my high risk status I also received IMRT radiation to the pelvic and many abdominal lymph nodes. All this with curative intent. Obviously the advantage of such coverage is that surgery simply can not reach such a large area without inflicting tremendous harm.PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

Believe me, if our radiation oncologists could limit or eliminate the dispersion of radiation outside the prostate, they would. In fact, this is the root cause of many (not all) of the late-term side effects from radiation therapy. They are not trying to have a shotgun pelt-spray effect...totally (word eliminated by mod) statement.

In fact, here's what the Prostate Cancer Foundation website says about this exact issue: "Because the prostate is close to several vital structures, prostate cancer and its treatments can disrupt normal urinary, bowel, and sexual functioning."____________________________BJ, please remember Rule 3.Post Edited By Moderator (Tudpock18) : 7/10/2019 4:58:26 AM (GMT-6)____________________________Tudpock, unlike your usual more "moderated" moderation, I think you jumped the gun on this one. Please observe that I did not say that the poster (the person) was stupid; rather, I said the comment was stupid. Calling the poster stupid would be a Rule#3 violation, and I wouldn't generally do that...that's an ad hominem attack (look it up). What I did was the opposite by clearly avoiding a personal attack; I attacked the issue (with supporting data) and NOT the person. If you don't like my use of the word "stupid," than say that...I'd change it to "goofy" or something a little less strong. But otherwise, how are we members to otherwise "call-out" the goofy nonsense that sometimes gets posted here? Again, frankly you should be promoting my reply as the model other members should follow: attack the issue, not the person. My original reply was not a Rule#3 violation.

Contemporary trends in treatment of PC continue to slowly evolve...you should research this on your own (use these key words). The most significant change is the uptake of AS as first-line therapy...not, however, the best choice for you. (There are various "protocols" for AS, not one universal, one-size-fits-all, in the US, in Australia, in Colombia...everywhere; but your 50% positive and +DRE logically exclude you from most.)

The second most significant trend in the last decade is the shift of radical prostatectomies being almost exclusively robotically-assisted, whereas 10 years ago it was about 50/50 "open" RP.

The third most significant trend in the last decade is the rapid near elimination of brachytherapy as a mono-therapy. 10+ years ago, nearly 10% of PC cases had first-line BT; today it's less than 2%. Many facilities have dropped BT, and schools are not generally teaching it...at least not here in the US.

EBRT+BT usage has remained steady (but low, overall) for high-risk cases (somewhere between 1-1.5% of all treatments), but dropped 25% for intermediate cases in 10-years, and is rare (<0.3%) today for low-risk cases such as yours.

With the increase in AS, all forms of radiation combined have taken most of the hit; the steady growth of RP in the preceding decade also flattened out. Patients undergoing treatment continue to be younger, which aligns better to RP compared to RT, contributing to the overall shifts. Overall, RP remains the most frequent treatment, EBRT second, SBRT is an emerging yet minor contributor, BT is going away.

I recently attended a local PCa support group that featured a panel discussion with a surgeon, radiation oncologist, and medical oncologist.

One of the most interesting take-aways was the radiologist stating that his large hospital had just installed new HDR-BT devices. He said that they were very unlike previous versions. Much easier on both the patients and doctors. He was highly impressed with the graphics that allowed very precise real time monitoring.

This was from a guy who had extensive experience with IMRT, SBRT, and protons.

So, I guess that we may be seeing a new dawning of HDR-BT.DOB: May 1944In Active Surveillance program at Johns HopkinsStrict protocol of tests, including PHI, DRE, MRI, and biopsy.Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.PSA 4.4, fPSA 24, PHI 32Hopefully, I can remain untreated. So far, so good.

I know this is really not related to this thread, but the last time I was at Dr. Moran's office (Chicago prostate center) I asked his assistant if anyone is training with the Dr. Her answer was no. I'm pretty sure he is in his early sixties and has performed 20k LDR procedures. He is pretty much the top 5 in his field, place is always busy, in other words, there a lot of people going there. Still Its interesting that when he stops it looks like there will be no one to replace him. On one of his blogs he even talks about Brachytherapy being a dying (art) procedure, not because it doesn't work, but because doctors are going different routes. Well, maybe I should re-phrase that last sentence… I sure hope it works.

I have had meals with RO's on cruises and other trips, and they told me that BT was declining not due to any performance deficiencies, but because it was less profitable for the providers. Insurance companies will pay a lot more for 40 treatments than for one or two sessions. I asked about SBRT, and they said that was now being paid reasonably well, but only after much argument.DOB: May 1944In Active Surveillance program at Johns HopkinsStrict protocol of tests, including PHI, DRE, MRI, and biopsy.Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.PSA 4.4, fPSA 24, PHI 32Hopefully, I can remain untreated. So far, so good.

As soon as ldog's post appeared about the disappearance of LDB, my inner cynic said, "it's about profitability". It's the perverse economics of medicine, where the supply/demand curves seem to be inverted. But that is a rant for another day.Age at Diagnosis: 56RALP on 2/17/15, BJC St. Louis, Dr. Figenshau58.5g, G3+4, 20%, 4 quadrants involvedPSA Non-Detect since April, 2015My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024

I had consultations at Sloan Kettering when I was researching procedures 4 1/2 yrs and I was interested in HDR-BT, but it was apparent that at the time it was done there only rarely as a mono therapy. But now see they have a new HDR program. So maybe there will be some renewed interest in places.

ASAdvocate said...I recently attended a local PCa support group that featured a panel discussion with a surgeon, radiation oncologist, and medical oncologist.

One of the most interesting take-aways was the radiologist stating that his large hospital had just installed new HDR-BT devices. He said that they were very unlike previous versions. Much easier on both the patients and doctors. He was highly impressed with the graphics that allowed very precise real time monitoring.

This was from a guy who had extensive experience with IMRT, SBRT, and protons.

There are many clinics in the Atlanta area providing both permanent seeds and High Dose Rate brachytherapy and I understand from my urologist that they are busy. My urologist says in his large practice that surgeries are down, AS is up and radiation is up. A very high volume surgeon left the practice a few years ago and there is a greater emphasis on AS in the practice overall. In addition to working with a clinic that uses HDR brachytherapy he also works with a young radiation oncologist that uses permanent seeds using CT scanning to place the seeds.

He has also reported several times over the past couple of years that there are proportionately more men further advanced at diagnosis. Many of these are choosing combination brachytherapy and IMRT instead of surgery with the high probability of either adjuvant or salvage radiation. This is in line with his initial treatment advice for me nearly nine years ago. He thinks fewer men are being routinely screened compared to 5-10 years ago. When I was diagnosed and for many years prior many groups sponsored free screening events several times a year. That appears to have completely stopped.PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

JNF said...My urologist says in his large practice that surgeries are down, AS is up and radiation is up.

The trend toward urology-owned radiology clinics has been harshly criticized by professional medical societies due to unethical self-referrals, but has been extremely profitable for many larger clinics across the country...so this local observation follows that pattern. LINK

JNF said...He has also reported several times over the past couple of years that there are proportionately more men further advanced at diagnosis. Many of these are choosing combination brachytherapy and IMRT instead of surgery with the high probability of either adjuvant or salvage radiation.

The first part of this is correct not only in his little world but also nationally, corresponding with the reduction of non-consequential PCs being diagnosed (aka, "smart" PSA testing), but in the big picture, nationally in the US, your reference to "many" high-risk cases being treated with EBRT+BT means about 2% and is on a slow downward trend, as I previously indicated. In 2014, for all PC cases (high-, intermediate- and low-risk combined), EBRT+BT was used for only 3.4% of all cases. LINK

Unsupervised, free PSA testing pop-ups, which were initially launched by drug companies trolling for customers (I've previously written about the interesting, albeit sordid, history of the PC-industry) are now deemed unethical. Do a site search.

He has also reported several times over the past couple of years that there are proportionately more men further advanced at diagnosis. Many of these are choosing combination brachytherapy and IMRT instead of surgery with the high probability of either adjuvant or salvage radiation. This is in line with his initial treatment advice for me nearly nine years ago. He thinks fewer men are being routinely screened compared to 5-10 years ago. When I was diagnosed and for many years prior many groups sponsored free screening events several times a year. That appears to have completely stopped.

The screening recommendations of 4 years ago, that have since been revised do seem to have had two seemingly opposite--but both predictable effects: On the one hand, there are fewer men getting screened, so there are fewer low risk diagnoses that end up with early or unneeded treatment. On the other hand, with fewer men being screened earlier, there are more men showing up with higher level initial diagnoses, that might well have been caught earlier if they had screened earlier. And, both of those outcomes were entirely predictable with the change in screening recommendations.

halbert, as JNF properly included: "proportionally." Not only was it predicted, these were elements of the goals...but that's onto another topic of other threads, on another day.

3-day weekend starts now...After a couple weeks in Europe, I'm easing slowly back into work. 3-day work week last week with the Independence Day holidays, 4-day work week this week...thankfully I've got a 6-day "weekend" in NC coming up starting next Friday...going to the Outer Banks (including a hike up the beautiful Cape Lookout lighthouse) and a concert in Raleigh. No need to rush back into work...

Blackjack, my urologist's practice does not own any radiation clinics. In the Atlanta area the largest seed practice (RCOG) is owned by Northside Hospital. Northside also owns the clinic where I had my HDR and IMRT treatment. They also perform SBRT. The other HDR clinics are Emory Hospital and Cancer Treatment Centers of America. So none of these are owned by urology practices. Your point about urologist owned radiation centers may be valid in other markets but your innuendo regarding Atlanta is incorrect and inappropriate.

Regarding my Urologist's practice, he has long said he would only operate when there was an extremely high probability surgery would be curative and not require salvage radiation. That precludes those diagnosed as high risk. He practices in such a way as to avoid the greater risk of more significant negative treatment side effects when one is exposed to both surgery and radiation. He also would not operate on low risk men as he was a very early proponent and adopter of AS treatment protocol and since his residency has determined that surgery for low risk is unnecessary over-treatment. . As such, he was not doing very many prostatectomies and stopped performing them several years ago. I like to share his professional approach as it appears to be rather unique. He is a urologist first, not a surgeon practicing in the area of urology. He looks to ways to avoid surgery and is a strong proponent of non-surgical treatments for PCa. If a PCa patient truly wants surgery, he refers them to one of his associates that is a full time PCa surgeon performing many each week. He specializes in prostate work (and continence issues in both men and women) with much of it being enlargement and BPH and he does surgical procedures where appropriate, just not for PCa.

Atlanta has a long history of large PCa radiation practices that makes it different than most other large cities and obviously doesn't follow the national trends cited by Blackjack. Since I was treated there are more radiation clinics for PCa not fewer. And has added a Proton Center. My urology group is the largest in Georgia and I have reported how their PCa practice has been changing which doesn't appear to be following the trends that Blackjack cites.PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

This 2018 research article found no significant difference in outcomes when triple combo treatments involving both RP and RT were used with G 9-10 patients.

https://www.ncbi.nlm.nih.gov/pubmed/30452521

This debate is being blurred by the fact that mono therapies are rarely used anymore for high risk cases. That makes future RP vs. RT comparisons complicated, and probably moot.DOB: May 1944In Active Surveillance program at Johns HopkinsStrict protocol of tests, including PHI, DRE, MRI, and biopsy.Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.PSA 4.4, fPSA 24, PHI 32Hopefully, I can remain untreated. So far, so good.

AS, I am not aware of mono-therapy BT (seeds or HDR) ever used in high risk cases. The RCOG here in Atlanta and other seeds doctors like Moran and the late Peter Grim use seeds with IMRT, except in low risk situations. Their use of seeds mono-therapy would have been limited to lower risk. You can see from the Demanes website that mono-therapy HDRBT is clearly not for high risk. My clinic explained to me at my dx that it would be combination HDRBT and IMRT due to my high risk dx. In the past few years they have been offering more mono-therapy HDRBT and basically follow the protocol established by Demanes and limit the practice to low and favorable intermediate risk, never high risk. Martinez in Detroit limits HDRBT mono-therapy to risk profile similar to Demanes. Emory Medical Center here in Atlanta offers both HDRBT and seeds and explain that the risk profile will determine when mono-therapy can be used.

I don't see any complication in comparing treatment therapy results and there have been numerous studies that we have all read. As long as there are multiple methods to approach PCa we will be reliant on such comparisons and they would not be moot in my opinion. While I find it good that there are several different PCa treatment methods that often can be pursued, it also complicates the decision making for many men. But we need these comparative studies to both guide the specialists with their protocols and their recommendations as well as for the patient in comparing different treatment methods.PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta